Provider Demographics
NPI:1295253110
Name:GENESIS MEDICA LLC
Entity type:Organization
Organization Name:GENESIS MEDICA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:AGGARWAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-865-3880
Mailing Address - Street 1:1427 CHAPEL ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-4403
Mailing Address - Country:US
Mailing Address - Phone:203-865-3880
Mailing Address - Fax:203-624-5609
Practice Address - Street 1:247 BROAD STREET
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-3267
Practice Address - Country:US
Practice Address - Phone:203-693-2230
Practice Address - Fax:203-693-2232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-30
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT036883207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty